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540 E. Herndon Ave. Suite 101 Fresno, CA 93720 559 431 0340 559 431 0301 fax www.DeMeraAllergy.comPEDIATRIC MEDICAL HISTORYPatient Name DOB Date Age Sex Ht Wt Primary Physician Referring Physician
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How to fill out pediatric medical history

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Step 1: Begin by collecting basic information about the child, such as their full name, date of birth, and gender.
02
Step 2: Ask the parent or guardian to provide details about the child's birth history, including any complications or surgeries.
03
Step 3: Record information about the child's immunization history, including dates of vaccinations and any adverse reactions.
04
Step 4: Ask about any ongoing medical conditions or diagnoses the child has, and document them in the medical history form.
05
Step 5: Inquire about any known allergies the child may have, including both medication and food allergies.
06
Step 6: Record information about the child's family medical history, including any hereditary conditions or diseases in close relatives.
07
Step 7: Document any medications the child is currently taking, including dosage and frequency.
08
Step 8: Ask about any previous hospitalizations or surgeries the child has undergone, and include relevant details in the medical history form.
09
Step 9: Inquire about the child's growth and development milestones, such as age at first walking and talking.
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Step 10: Finally, review the completed pediatric medical history form with the parent or guardian, ensuring all information is accurate and up-to-date.

Who needs pediatric medical history?

01
Pediatric medical history is needed by healthcare professionals who provide care to children, including pediatricians, pediatric nurse practitioners, and pediatric specialists.
02
Parents and guardians also need the pediatric medical history for their child's records and to provide necessary information to healthcare providers.
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Pediatric medical history is a comprehensive record of a child's past and ongoing health issues, treatments, surgeries, immunizations, and family medical history, which helps healthcare providers understand the child's health context.
Pediatric medical history is typically filed by the child's parents or guardians, and may also be completed by healthcare providers involved in the child's care.
Pediatric medical history can be filled out by collecting information through questionnaires, interviews, and medical records that detail the child's health conditions, treatments, and family history.
The purpose of pediatric medical history is to provide healthcare providers with essential information that aids in diagnosing, treating, and preventing health issues in children.
Information required includes personal identification, past illnesses, surgeries, family medical history, allergies, immunization records, medications, and developmental milestones.
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